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Managed Care: Rationing Without Justice, but Not Unjustly

Author

Buchanan, Allen

Bibliographic Citation

Journal of Health Politics, Policy and Law. 1998 Aug; 23(4): 617-634.

Abstract

Three ethical criticisms of managed care are often voiced: (1) by
"skimming the cream" of the patient population, managed care organizations
fail to discharge their obligations to improve access, or at least, to not
worsen it; (2) managed care organizations engage in rationing, thereby
depriving patients of care to which they are entitled; and (3) by pressuring
physicians to ration care, managed care organizations interfere with
physicians' fulfillment of their fiduciary obligations to provide the best
care for each patient. This article argues that each of these criticisms is
misconceived. The first rests on the false assumption that the health care
system includes a workable division of responsibility regarding access that
assigns obligations concerning access to managed care organizations. The
second and third criticisms wrongly assume that we in the United States have
taken the first step toward assuring equitable access to care for all,
articulating a standard for what counts as an "adequate level of care" to
which all are entitled. These three misguided criticisms obscure the most
fundamental ethical flaw of managed care: the fact that it operates in an
institutional setting within which no connection can be made between the
activity of rationing and the basic requirements of justice.

Two basic criticisms of managed care are that it erodes patient trust
in physicians and subjects physicians to incentives and pressures that
compromise the physician's fiduciary obligation to the patient. In this
article, ...